Provider Demographics
NPI:1477078244
Name:COSTELLO, CORY LYN (BS, LMT, NMT)
Entity Type:Individual
Prefix:MS
First Name:CORY
Middle Name:LYN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:BS, LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-2059
Mailing Address - Country:US
Mailing Address - Phone:406-868-6316
Mailing Address - Fax:
Practice Address - Street 1:1601 2ND AVE N STE 516
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3289
Practice Address - Country:US
Practice Address - Phone:406-868-6316
Practice Address - Fax:406-868-6316
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-13
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-10081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist